Can result from disease/deficiency of the pituitary gland itself or disease of the hypothalamus; the result is essentially the same

What is Acromegaly?

Excess GH after the epiphyseal plate closure

What is the Epiphyseal plate closure?

Once the body reaches maturity, all the cells responsible for new bone growth ossify or solidify into bone and this progression stops, thus bringing on epiphyseal closure. At this time the plate transforms into the epiphyseal line, the only remnant of the growth process.When problems occur with the epiphyseal closure of a bone or bones, changes in the body’s structure or height can be evident. For example, if epiphyseal closure occurs before full maturity is reached, normal height may not be attained. When closure does not occur, the long bones will continue to grow allowing the individual to surpass natural height. These abnormal changes can also affect the shape of the long bones and create irregular formation resulting in deformities.

The disease cannot be controlled by limiting fluid intake,because the high-volume loss of urine continues even without fluid replacement. Attempts to restrict fluids cause the patient to experience an insatiable craving for fluid and to develop hypernatremia and severe dehydration.

What 4 diagnostic tests are done to diagnose DI?

1) Fluid Deprivation test

2) Plasma Levels of ADH & osmolaltiy

3) Urine Osmolality

4) Synthetic Vasopressin trial

What is the Fluid Deprivation Test?

Test done to diagnose DI. The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patient is weighed frequently during the test.Plasma and urine osmolality studies are performed at the beginning and end of the test. The inability to increase the specific gravity and osmolality of the urine is characteristic of DI. The patient continues to excrete large volumes of urine with low specific gravity and experiences weight loss,increasing serum osmolality, and elevated serum sodium levels. The patient’s condition needs to be monitored frequently during the test, and the test is terminated if tachycardia,excessive weight loss, or hypotension develops.

Is the surgical removal of the hypophysis (pituitary gland). It is most commonly performed to treat tumors, especially craniopharyngioma tumors. Sometimes it is used to treat Cushing's syndrome due to pituitary adenoma.

During post op care of a patient that underwent Hypophysectomy should you elevate the HOB?

yes. you should elevate the HOB

During post op care of a patient that underwent Hypophysectomy what should you monitor?

I&O, electrolytes, osmolality

During post op care of a patient that underwent Hypophysectomy a pt may have a nasal drip pad. What should you monitor for and do if you see?

–Monitor the condition or quality of what you see on the drip pad

•Halo= CSF

–Do glucose test

During post op care of a patient that underwent Hypophysectomy a pt having this kind of drain will be rare.

lumbar drain

Where is the possible incision sites for a pt that underwent a Hypophysectomy?

–Under upper lip along gum line or through

the nose

•Be careful when brushing hard here

•Avoid alcohol content bc it will irritate

area

–Abd incision- fat graft site

•Will be small

•May or may not have sutures

A pt coming back from a hypophysectomy surgery will probably have what for how long?

foley cath for 24-48 hrs

they will also be thirsty!

What important D/C teachings to be done for a pt that underwent a Hypophysectomy?

–Brushing teeth

•Oral care very important

•Be careful when brushing hard at incision

site

•Avoid alcohol content bc it will irritate area

–Caution re: activity that increase ICP

•Watch activity even after they go home

•Watch for pressure that will increase

intracranial pressure (coughing,

straining, weight lifting, sneezing)

•Don’t want to bend or get head lower

than the waist for a month after

HYPOthyroidism= TSH, T4, and T3 (high or low) values.

High TSH

Low T4

Low or normal T3

= HYPOTHYROIDISM

HINT: T4 tells if hypo or hyper if it's high it hyperthyroidism; low is hypothyroidism

HYPERthyroidism= TSH, T4, and T3 (high or low) values.

Low TSH

High or normal T4

High or normal T3

=HYPERTHYROIDISM HINT: T4 tells if hypo or hyper if it's high it hyperthyroidism; low is hypothyroidism

A thyroid assessment includes what 4 things?

•Physical Exam

–Visualize neck, look for signs of swelling

and nodules, check for tracheal shift (if

extreme you will see), palpate and

should not be able to feel them, have

pt swallow and you will feel the muscles

shift

•Ultrasound

•CT/ MRI

–2nd choice

•Laboratory

–Serum TSH

–Free T4

–Serum T3 , T4

What is Goiter?

Abnormal enlargement of the thyroid gland

Goiter can occur with what 3 things?

–Hyperthyroidism

--high

–Hypothyroidism

--low

–Euthyroidism

--normal

REMEMBER!

Just bc there is a growth does not mean there is a goiter and thyroid is not funtioning properly. Run tests to check to find the problem

What cause Goiter?

Iodine deficiency. In this later condition, lack of iodine results in low levels of circulating thyroid hormones, which causes increased release of TSH; the elevated TSH causes overproduction of thyroglobulin (a precursor of T3 and T4) and hypertrophy of the thyroid gland.

Diagnostic procedures done to test the thyroid include these 5

•Thyroid antibodies

•Radioactive iodine uptake

•Fine-needle biopsy

•Thyroid scan, radio scan

•Serum thyroglobulin

What is Hyperthyroidism?

Hypersecretion of T3 & T4

What 5 things can cause Hyperthyroidism?

Causes:

–Decrease TSH from pituitary

–Autoimmune reaction (Graves’ disease)

•Most common cause

–Inflammation/viral infection

•Another common cause

–Tumor

–Excessive dose of thyroid replacement

•Ppl who want to lose weight so they

overdose on thyroid meds

What is a Thyroid Storm/Crisis?

Acute,life-threatening

Thyroid storm has a sudden onset. It can

be fatal if left untreated. Have to be sent to ICU

What cause a Thyroid Storm/Crisis?

--Severe infection/stress

--Manipulation of thyroid gland

--Post-thyroid surgery

--Sudden alteration in medication

--Person having a MI has a thrown off hyperthyroid

--Vigorous palpitation of thyroid

4 S/S of Thyroid Crisis/Storm?

–Temp >101.3

•Elevated and can go as high as 106

–Increased HR, systolic HTN

•Greater than 130

–Agitation,confusion, seizure

•Due to all the activity

–Exaggerated S/S of hyperthyroidism

Treatment for Thyroid Storm/ Crisis pt includes:

Keep pt calm

Limit visitors

Limit any kind of stimuli

Want them in a quiet area on the unit

Try to treat thyroid (may use cardiac meds to keep HR down)

A Thyroid Storm/Crisis pt is at greatest risk of what?

Cardiovascular problems

What is Thyroiditis?

Inflammation of the Thyroid

What are the 3 Types of Thyroiditis?

Acute

Subactute

Chronic

Acute Thyroiditis is..?

–Infection

– bacteria, fungal or parasites

Symptoms of Acute thyroiditis:

–Pain, swelling, dysphagia, dysphonia, & S/S of hyperthyroidism

•Onset is fast

•Confined to one side of the neck usually

•Fever and chills with certain infection

Treatment of Acute Thyroiditis:

antibiotic, fluid replacement

–Function returns after treatment

•Couple of days up to a couple of weeks

What is Subacute Thyroiditis?

Granulomatous–viral

Usually after some upper respiratory problem

Symptoms of Subacute Thyroiditis

–low-fever,fatigue, swelling, pain not as severe, trouble swallowing

Phase 1 of Subacute Thyroiditis show signs and symptoms of hyperthyroid at how many months?

hyperthyroid S/S (1-3 mo.)

Phase 2 of Subacute Thyroiditis show signs and symptoms of hyperthyroid at how many months?

hypothyroid S/S (9-12 mo.)

Treatment of Subacute Thyroiditis

NSAIDs,b-blockers, steroids

function-- normal after 12-18 months to fully resolve

What is Chronic Thryroiditis?

What is it also know as?

Damage and destruction of thyroid, slow onset, does not have painful S/S

–Chronic lymphocytic -- autoimmune

Thyroid

will never go back to normal

What are the symptoms of chronic thyroiditis (Hashimoto's Disease)?

painless, hypothyroid S/S

slow onset

What are the treatment of chronic thyroiditis (Hashimoto's Disease)?

thyroid replacement

Function: hypothyroidism permanent

Thyroid will never go back to normal

What are the risk factors of chronic thyroiditis (Hashimoto's Disease)?

Family history

History of R.A., Addisons disease, Type 1 diabetes

When assessing a pt with hyperthyroidism you can expect what 8 cardinal things?

–Increased Basal Metabolic Rate

--caused weight loss

–Nervousness, tremor

–Exophthalmos (Graves)

•Granopathene: Rash that shows up on

shins

–Painless,red

–Increased T, P, R, & BP

–Wt loss, Hunger

–N/V, diarrhea

–Weakness, fatigue

–May have enlarged thyroid (goiter)

•May or may not have enlarged thyroid

What nursing interventions should you monitor and assess for a pt with hyperthyroidism?

•Have pt rest in cool quiet environment

--Pts are irritable, nervous

•Daily wt

–Make sure they are keeping up their

calorie count like they need to

•Nutrition

–May get by with low fiber diet bc we

want the gut to slow down

•Monitor for thyroid storm

•Monitor for hypothyroidism after treatment

•Education r/t lifelong therapy

--avoid stimulants (starbucks, red bull,

decongestants, diet pills)

--Smoking stimulates thyroid so want

them to stop smoking

--Good patient teaching and warn of the

risks of stopping suddenly

A hyperthyroid treatment includes what 4 treatment options?

•High-calorie diet

•Anti-thyroid medications

•Radioactive Iodine – I131

•Thyroidectomy

--thyroid hormone replacement (post-op)

Anti-thyroid medications for hyperthyroid treatment include (2)?

methimazole (Tapazol) & propylthiouracil (PTU)

What is Radioactive Iodine I131?

–Permanent treatment for the hyperthyroid

–Take po and it will go only to places where

there is iodine uptake

–It will absorb the iodine and damage or kill

it

–Can be done on an outpatient basis

depending on the dosage and the pts

condition

–Results can be seen in about 1-2 months

–Radioactive for 3 months or sometimes

longer

•Don’t want them/or other ppl handling their

body wastes

–Side effects: monitor thyroid levels incase

they go to a hypothyroid state

Thyroidectomy is the treatment of choice for what?

Thyroid cancer

For a thyroidectomy it can either be partial or total. The surgery may include:

–Modified or radical neck dissection

–Radioactive iodine to minimize metastasis

What nutrition pre-op teaching should you include for a pt going to thyroidectomy surgery?

Dietary guidance to meet metabolic needs

What things should you tech a pt to avoid during pre-op teaching of a thyroidectomy pt?

Avoid

•Caffeine & other stimulants

What things should you explain to a patient that is headed for thyroidectomy surgery?

–Explanation

•Of tests and procedures

–Demonstration of postoperative Head support

--lifelong thyroid replacement may be

required

•Total=lifelong treatment replacement

How do you want the HOB to be for a pt in post-op for thyroidectomy surgery?

--at least 30 degrees

--want gravity to help with part of swelling

What is the #1 priority of a pt in post-op after thyroidectomy surgery?

Monitor airway!!

Check O2

What should you teach your patient if they are trying to get up after thyroidectomy surgery?

Have pt roll on their side or use arms to raise up and support the back of the head.

The flatter the pt is, the more strain there is

Why should you watch for decrease in Ca for a post op thyroidectomy pt?

Low Ca leads to tetany

Will a person with thyroidectomy have to have lifetime thyroid replacement?

It depend on whether or not they have a total or partial thyroidectomy.

Total is lifetime, partial is not

What is hypothyroidism?

Insufficient T3 & T4

TSH = high

What causes hypothyroidism?

–Antibody mediated destruction of

thyroid (Hashimoto’s Disease)

–Thyroiditis, infection

–Iodine deficiency (goiter)

–Pituitary decrease secretion of TSH

What signs and symptoms are key to myedema coma?

Puffy face and soft tissue selling in edema around eyes, ptosis, enlargement of the tongue are key to myxedema coma

What is myedema coma?

Severe hypothyroidism!

What causes myxedema coma?

–Sudden d/c thyroid replacement

–Acute illness

What 4 things should you assess for on myedema coma pt?

–S/S hypothyroid

–Hypoglycemia

–Edema

–Possible pleural effusion

In general.. Hypothyroid pts are usually?

cold

have cool, dry skin

slow HR/bradycardic

Low BP

Extreme fatigue

--sleep for 8 hrs and don't feel like they

slept for 1

--greater tendency for depression

--gut slows down

What cause hypothyroidism?

Infection

Associated with CHF & MI

Hypothyroid assessment vary with what 2 things?

severity and length of time

Lab values for a hypothyroid pt will have high ____ & ____ and low ____, ____. They will also have decreased ____ and ____.

If a parathyroidectomy does not work what is another procedure option if hyperparathyroid is extremely critical?

dialysis

During pre-op of a parapthyroidectomy you should monitor what 3 electrolytes?

Ca, Phos, Mg

The head of the bed should be elevated to how high for a parathyroidectomy pt.?

at least 30 degrees

What is the #1 priority for at pt post op parathyroidectomy?

airway and oxygenation!

You should monitor for tingling in what for a pt post op thyroidectomy.

tingling in extremities or face

A pt post-op parathyroidectomy may speak in a hoarse voice or whisper. You should monitor if they can talk in an normal tone or if they can talk at all. If pt is having difficulty then you may want to consider what?

If speech problems then look at therapy or rehab option

You should educate a post op parathyroidectomy pt to take Ca and vit D supplants as prescribed. You also teach them to guard and protect what?

guard throat and protect incision

Ypu should monitor what 2 things in a hyperparathyroid pt?

VS, esp BP

A hyperparathyroid pt need s to be taught safety precautions when..?

They are brought back form surgery. They need to know they need to roll on their side to protect their neck form straining when getting up. They also need to know their neck is probably sore form manipulating it during surgery.

Why does a hyperparathyroid pt need to be hydrated?

Due to excess Ca circulating there is a possibility of kidney stones. If the pt takes in at least 2000 mL of fluids then they decrease the risk of calcium callusing in the kidneys and forming kidney stones

For a hyperparathyroid pt a nurse should monitor for what two things?

monitor for tetany & dysrhythmias

A hyperparathyroid pt is at risk for ..?

altered elimination

What is hypoparathyroidism?

Deficiency of PTH related to decreased Ca

Manifestations a hypoparathyroid pt include what 5 things?

-- BP

-- GI symptoms

-- Irritable, nervous, tract

-N/V/D

--Numbness & tingling: face or extremities

-- Muscle cramps: abd or extremities

-- Anxious, irritable, depression

A hypothyroid pt is at risk for what 2 things?

Bronchospasm, laryngeal spasm

Tetany usually happens when Ca levels are?

less than 6

What the normal Ca levels?

8.6-10.2

Positive Trousseaus and Chvosteks signs are a manifestation of what?

hypoparathyroidism bc of decreased Ca

Hypoparathyroidism has lab values of decreased ____ and ____; and increased ____?

Deceased PTH and serum Ca.

Increased serum phosphate

Someone is at risk of a hypoparathyroidism if they have had thyroidectomy and what was removed?